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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 22  |  Issue : 2  |  Page : 88-91

A fatal case of Listeria monocytogenes meningitis and sepsis in an immunocompromised female


Department of Microbiology, Sree Gokulam Medical College and Research Foundation, Venjarammoodu, Kerala, India

Date of Submission25-Jan-2021
Date of Decision06-Feb-2021
Date of Acceptance11-Feb-2021
Date of Web Publication5-Apr-2021

Correspondence Address:
Dr. Ashna Ajimsha
Department of Microbiology, Sree Gokulam Medical College and Research Foundation, Venjarammoodu - 695 607, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacm.jacm_33_21

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  Abstract 


Listeria monocytogenes should be considered as a source of sepsis and meningitis in immunocompromised individuals. Immunosuppressant agents including biologic therapies have transformed the management of various rheumatological and dermatological conditions. We report a case of life-threatening Listeria monocytogenes sepsis and meningitis in a 52-year-old female who was on immunosuppressive therapy.

Keywords: Immunocompromised female, Listeria monocytogenes, meningitis, sepsis


How to cite this article:
Ajimsha A, Viswamohanan I, Krishna GR, Jitendranath A, Bai R. A fatal case of Listeria monocytogenes meningitis and sepsis in an immunocompromised female. J Acad Clin Microbiol 2020;22:88-91

How to cite this URL:
Ajimsha A, Viswamohanan I, Krishna GR, Jitendranath A, Bai R. A fatal case of Listeria monocytogenes meningitis and sepsis in an immunocompromised female. J Acad Clin Microbiol [serial online] 2020 [cited 2021 Apr 23];22:88-91. Available from: https://www.jacmjournal.org/text.asp?2020/22/2/88/313076




  Introduction Top


Listeria monocytogenes is a Gram-positive, non-sporing, aerobic bacillus that is motile at room temperature and non-motile at 37°C. Morphological description of the organism was first done by Murray et al. in 1926. Only Listeria monocytogenes and Listeria ivanovii are associated with diseases in humans. The organism may resemble diphtheroid species, streptococci or pneumococci on direct smears and hence the problem in identification and the chance of regarding as a contaminant in the laboratory making its identification important. Clinically, Listeria monocytogenes causes meningitis and sepsis in immunocompromised individuals. Among the cases of invasive listeriosis, 25% occur in pregnant women. The annual incidence of listeriosis in Europe ranges from 0.1 to 11.3 cases per million. In the United States, the incidence reported in 1992 was 7.4 cases per million. In India, there were no case reports on Listeria till 1973. In 1981, a prospective study of 1300 births documented 2.2% as the prevalence rate of Listeria in meconium-stained babies and 0.2% of live births.[1]


  Case Report Top


A 52-year-old female was a known case of chronic liver disease with portal hypertension (hepatitis C induced) on treatment, on further evaluation for arthritis, she was found to have antinuclear antibody positive and was put on steroids and immunosuppressants (dexamethasone and hydroxychloroquine) for six months. She is also a known case of Type 2 Diabetes mellitus. She came with complaints of fever for two days and bleeding per vaginum for one day. She was found unconscious in the morning at home by her daughter. Urinary incontinence was present. She regained consciousness in four hours, after which she had altered sensorium. On examination, the patient was restless, involuntary movements were present, her blood pressure and blood sugar levels were elevated, she was afebrile and neck rigidity and bilateral extensor plantar reflexes were present.

She was admitted in the intensive care unit and routine investigations were sent. Computed tomography (CT) of the brain was normal. Her liver function tests were deranged. Total count, C-reactive protein, procalcitonin and erythrocyte sedimentation rate were elevated. She developed saturation fall, tachypnoea and tachycardia and was started on non-invasive ventilation (NIV).

Since the patient had features of acute meningitis, blood and cerebrospinal fluid (CSF) samples were sent for Gram stain and culture and sensitivity. CSF analysis revealed high total count – 145 cells (Differential Count- Neutrophils-9%, Lymphocytes-91%), protein – 260.8 mg/dl and sugar – 36 mg/dl. She was started on injection Ceftriaxone, injection Vancomycin and injection acyclovir. Tachypnoea persisted in spite of NIV support, so she was mechanically intubated and ventilated in view of respiratory failure. She developed fever spikes. Direct smear of CSF showed lymphocytes and 0.5 μm × 2–3 μm, Gram-positive bacilli, arranged singly, non-sporing and not capsulated. Two blood samples were sent (right and left hand). Growth was detected on BacT/ALERT 3D. The direct Gram-stained smear showed 0.5 μm × 2–3 μm, Gram-positive bacilli, arranged singly, non-sporing and not capsulated [Figure 1] and [Figure 2].
Figure 1: Blood direct smear

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Figure 2: Cerebrospinal fluid direct smear

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Subcultures were done on blood agar, chocolate agar and McConkey agar as per the protocol and incubated at 37°C overnight. On blood agar and chocolate agar, 0.5–1.5 mm, smooth, translucent grey colonies were seen [Figure 3] and on McConkey agar, 0.5–1.5 mm lactose fermenting colonies were seen.
Figure 3: 0.5–1.5 mm, smooth, translucent grey colonies on Blood agar

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After 18–24 h of incubation, the colonies on blood agar developed a narrow zone of β-haemolysis. On longer incubation, the haemolysis was more evident. Colony smears also showed 0.5 μm × 2–3 μm, Gram-positive bacilli, arranged singly, non-sporing and not capsulated. Motility was observed in hanging drop preparations prepared from overnight broth culture incubated at 22°C and examined at 6 and 8 h. Tumbling motility was observed at 22°C and it was non-motile at 37°C.

Oxidase test was negative. Catalase test, Christie, Atkins and Munch–Peterson test, bile aesculin agar [Figure 4] and [Figure 5] hydrolysis test, methyl red test and Voges–Proskauer test were positive. Glucose, maltose, L-rhamnose and α-methyl D-mannoside were fermented producing acid without gas. The isolate was susceptible to Penicillin, Ampicillin, Amoxicillin Clavulanic acid, Aminoglycosides, Tetracycline, Erythromycin, Cotrimoxazole, Imipenem, Vancomycin and Rifampicin. On VITEK 2-automated system, the organism was identified as Listeria monocytogenes.
Figure 4: Bile aesculin agar hydrolysis positive

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Figure 5: Christie, Atkins and Munch–Peterson test positive

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Antibiotics were changed to injection Ampicillin and injection Gentamycin. Her fever spikes subsided, but she could not be weaned off from ventilator support. Repeat CT showed diffuse cerebral oedema and acute non-communicating hydrocephalus. The patient was clinically deteriorating. She expired after three days.


  Discussion Top


Listeria monocytogenes is a Gram-positive rod. Incubation period of the disease averages about 3–4 weeks with a range of 3–90 days.[2] It is known to cause sepsis and meningitis mainly in elderly patients, pregnant women, neonates and immunocompromised hosts. It can be acquired through food, notably soft or unpasteurised cheese, unwashed vegetables and uncooked meat. The spectrum of clinical syndromes caused by Listeria is wide and includes febrile gastroenteritis, bacteraemia, meningitis and meningoencephalitis. Focal infections such as septic arthritis, endocarditis and cholecystitis have also been described.[3] Early recognition of listeria infections, especially listeria meningitis, is important due to its high mortality. Unlike other causes of bacterial meningitis, listerial meningitis may not show typical meningeal signs such as nuchal rigidity and is often complicated by encephalitis. Listeriosis during pregnancy may lead to abortion, stillbirth or delivery of an acutely ill infant. These diverse clinical manifestations reflect the bacteria's capacity to cross intestinal, blood–brain and placental barriers. Its virulence is attributed to its capacity to multiply at low temperatures or in refrigerated products and form biofilms. Listeria monocytogenes meningitis should be considered in cases of community–acquired bacterial meningitis that fail to respond to routine antibiotics such as third-generation Cephalosporins and Vancomycin. The combination of Ampicillin and a synergistic Aminoglycoside is generally considered as an optimal treatment of listerial meningitis. In patients allergic to beta–lactams, Sulfamethoxazole–Trimethoprim is the best alternative. Duration of treatment in meningitis is three weeks and a minimum of six weeks in brain abscess. Antibiotics should be continued until brain imaging studies document-resolving lesions.[4] Although listeriosis is common in neonates, children more than one year and adults may also be affected. About one-third of the patients with meningitis have no predisposing conditions. It may occur even in healthy children and adults.[5]


  Conclusion Top


Even though is an uncommon pathogen, clinicians should consider this organism as a source of sepsis and meningitis in immunocompromised individuals. In our patient, it is worth mentioning that she had been on multiple courses of steroids which may have contributed to the underlying immunosuppression. The meningitis UK guidelines suggest prescribing Ampicillin for all patients with suspected meningitis above the age of 55 years to cover for Listeria. Our case also raises the discussion as to whether all immunocompromised patients (regardless of their age) suspected of meningitis should be treated empirically with Ampicillin to cover for Listeria. Finally, hydrocephalus should be suspected in patients with meningitis (listeria meningitis in this case) who develop a reduced conscious level which may help to guide any subsequent interventions.[3]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kalyani M, Rajesh PK, Srikanth P, Mallika M. Listeria monocytogenes – A case report. Sri Ramachandra Journal of Medicine, 2006;1:145–46.  Back to cited text no. 1
    
2.
Winn WC, Koneman EW. Koneman's Color Atlas and Textbook of Diagnostic Microbiology. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 845-53.  Back to cited text no. 2
    
3.
Rana F, Shaikh MM, Bowles J. Listeria meningitis and resultant symptomatic hydrocephalus complicating infliximab treatment for ulcerative colitis. JRSM Open. 2014;5:1-3.  Back to cited text no. 3
    
4.
Rao K, Rangappa P, Jacob I, Mahadevaiah T. A rare case of Listeria monocytogenes meningitis in an immunocompetent adult. Indian J Crit Care Med 2018;22:892-3.  Back to cited text no. 4
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5.
Ramani Bai JT, Bhargavi L, Indu P, Deepthi G Nair, et al. Listeria meningitis. The Journal of the Academy of Clinical Microbiologists 2001;3:29-32.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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